Monica Bharel and Jessie M. Gaeta Boston Health Care for the Homeless Program NHCHC May 2014

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1 Monica Bharel and Jessie M. Gaeta Boston Health Care for the Homeless Program NHCHC May 2014

2 Data analysis at a population level Implications for our care model Facilitated discussion Population management Examples and outcomes

4 Individual Individual patient narratives Individual Individual patient outcomes Population Population level data collection, comprehension and outcomes

5 State and Federal Coverage N % Medicaid and Medicare 1,760 27% Medicaid only 4,733 73% Total 6, % M.Bharel et al AJPH Dec 2013

6 All (N=6,494) Mental Illness 4,384 (68%) Schizophrenia 1264 (19%) Bipolar Disorders 1889 (30%) Depression 3068 (47%) Anxiety 2627 (40%) Substance use disorders 3890 (60%) Alcohol use disorder 2628 (40%) Drug use disorder 3118 (48%) Co-occurring mental illness and substance use 3135(48%) M.Bharel et al AJPH Dec 2013

7 Chronic Condition Hep C HIV Cirrhosis Asthma/COPD HTN Ischemic HD Diabetes Percentage M.Bharel et al AJPH Dec 2013

8 $75,000 $78,660 $50,000 $58,896 $65,019 $36,810 $40,808 $39,236 $38,422 $25,000 $0 COPD or Asthma Hepatitis C Diabetes Ischemic Heart Disease HIV Congestive Heart Failure Cirrhosis N 1,711 1,473 1, M.Bharel et al AJPH Dec 2013

9 3,000 Numbers of Patients with Selected Behavioral Diagnoses 3,117 3,067 2,628 2,626 2,000 1,888 1,764 1,000 1,263 - Drug Use Depression Alcohol Use Anxiety Bipolar Disorder Schizophrenia Other Mental Illness % of all patients 48% 47% 40% 40% 29% 19% 27% M.Bharel et al AJPH Dec

10 $30,000 $29,780 $20,000 $10,000 $13,514 $6,041 $0 No Behavioral Dx Substance Dx Only Mental Health Dx N 1, ,383 M.Bharel et al AJPH Dec 2013

70% 60% 50% 40% 30% 20% 10% 0% 66% Proportions of Patients by Numbers of Inpatient Stays 15% 7% 8% 2% 2% 0 1 2 3-6 7-9 >9 Number of Inpatient Stays By comparison, 8% of the entire U.S. population in 2007 used hospital care.

11 70% 60% 50% 40% 30% 20% 10% 0% 66% Proportions of Patients by Numbers of Inpatient Stays 15% 7% 8% 2% 2% >9 Number of Inpatient Stays By comparison, 8% of the entire U.S. population in 2007 used hospital care. Among Massachusetts dual eligibles under age 65, whose average costs are similar to those of BHCHP patients, 18% had a hospital stay.* *2007 National Health Interview Survey; Breslin Davidson and Dreyfus, Dual Eligibles in Massachusetts, September M.Bharel et al AJPH Dec 2013

Proportions of Patients by Number of Emergency Room Visits 30% 31% 30% 20% 10% 18% 14% 7% 0% 0 1-2 3-5 6-12 >12 Number of Emergency Room Visits N 2,006 1,938

12 Proportions of Patients by Number of Emergency Room Visits 30% 31% 30% 20% 10% 18% 14% 7% 0% >12 Number of Emergency Room Visits N 2,006 1,938 1, The average number of ER visits for all patients was 4.0. Of the visits, 64% were to BMC, Cambridge Hospital, MGH or Tufts. M.Bharel et al AJPH Dec 2013

13 $720 $3,401 $10,023 $148,910,462 $47,250 M.Bharel et al AJPH Dec 2013

14 Medicaid-Only Duals Combined Expenditures $100,812,960 $48,099,906 $148,912,866 Patients 4,733 1,760 6,493 Average* $21,300 $27,329 $22,934 *Average expenditures were calculated simply as expenditures divided by number of patients without adjustment for partial-year membership. M.Bharel et al AJPH Dec

16 First, reactions to this data?

17 Facilitated group discussion Break into groups Answer 3 questions Report out in 15 minutes

18 What are some key elements of a care model that would improve the health of a group of similarly high risk people? What are the challenges of implementing a care model for individuals at high risk? How can we measure the impact of a care model?

19 Key Elements of a Care Model? Mental health services Case management, intensive CM Permanent Supportive Housing Continuity of care team, medical home Group visits with disease specific care teams Addiction services Integrative health, inc BH, other holistic services Simple process, immediate access Improved communication across health care system

20 Key Elements of a Care Model? (cont) Access to medication, integration of clinical pharmacy services Coordination with hospitals for right care at the right time and right place Working across clinics and systems Street outreach, mobile facilities Interdisciplinary providers-bh and medical care Medical respite Investment in risk stratification and population management-access to data and data analyst Harm reduction services, prevention

21 Key Elements of Care Model? (cont) Cultural competence Access to addiction services, including relapse prevention, continuum of care On-site specialty care and/or transportation to specialty care Focus on transitions of care Uniform medical records/access to medical records Employment and education services Community ownership of all members of communitydecrease social isolation Measure readiness of change with patients/clients and providers

22 CHALLENGES TO IMPLEMENTATION? Predictive models and access to data not yet available Identifying highest users/lack of data-resources are limited Identifying a person as homeless in the data Lack of health info exchange Current FFS reimbursement How to risk adjust, set capitated rate Care coordination across system Limited resources Unmet need, access to multiyear data MEASURE IMPACT? Patterns of utilization Evaluate data at individual level For top 10% and other 90% (improved overall access) Patient/client satisfaction/engagement Unmet need and preventive health care Improved health outcome Reduction in cost

23 Examples and Outcomes

24 1. PCMH Enhanced Care for highest risk people 2. Community support workers engage vulnerable, newly housed people 3. PSH for people with frequent ED visits

25 Risk stratification tool created 200 patients designated most vulnerable Enhanced care model includes: Designation in EHR Clinical care management by RNs Case conferencing by multidisciplinary teams Separate tracking of quality measures

29 Program-wide rate = Enhanced Care Pts. Rate

30 Program-wide rate = Enhanced Care Pts. Rate

31 Within each PCMH team, added a community support worker to engage Enhanced Care patients who were recently housed but not doing well Case load of each worker is 20 patients Mobile outreach, intensive case management Home visits with PCPs Tracking of utilization of ED and hospital, quality measures

32 st Qtr Rate of Hospital Overnights (overnights per month) 3rd Qtr Rate of Emergency Room Visits (visits per month) East West North 6 months before engagem ent with CHW after engagement with CHW N = 68 patients 9% decrease in hospital utilization after engagement with CSW 60% decrease in ER utilization after engagement with CSW 100 percent housing retention 81% of women up to date with cervical cancer screening 63% of women up to date with breast cancer screening 66% of patients with diabetes have A1C under 9

33 Define high user Minimum of 10 ED visits in any 6 month period Individuals identified from: Medicaid Local Emergency Departments Current target population identified is 200 individuals

34 To improve health and housing outcomes for chronically homeless high users of emergency services. To place participants in permanent housing and provide support services necessary for housing retention. To reduce the utilization of expensive emergency medical services and promote coordinated primary care, behavioral health, and addiction services.

35 IDENTIFICATION OF PATIENTS INTEGRATED PRIMARY CARE COORDINATION Medicaid Addictions Services Primary Care Mental Health Hospitals Case Management Oral Health BHCHP Barbara McInnis House Medical Respite as Platform IDENTIFY HIGH USER PERSON OUTREACH & ENGAGE Hospital Street Shelter Home CARE TEAM: Focus On IMPROVED HEALTH & LESS NON-PRODUCTIVE COSTS CONNECTION TO HOUSING OPPORTUNITIES Prioritize congregate housing (development needed) via housing partners. INTEGRATED PRIMARY CARE Specialized Management of Chronic Disease Preventative Care Management SUBSTANCE ABUSE TREATMENT Harm reduction Motivational interviewing Connect to treatment continuum PROMOTION OF COMMUNITY Groups Day Health Programs Social Support Services IMPROVED CARE TRANSITIONS Close Coordination with hospital EDs and inpatient services

36 56% reduction in emergency department visits 33% reduction in inpatient hospital stays % reduction in EMS ambulance transports ED visits/mo nth Inpatient nights/mo nth 18.3 EM S Trans/mo nth n=26 Before Housing During Housing

37 Accurate data is critical in understanding population characteristics Care model should be informed by data and tailored to meet the needs of a specific population Tracking outcomes is key component to success of care model

Social Determinants of Health: Advocating on behalf of our patients

Social Determinants of Health: Advocating on behalf of our patients MONICA BHAREL, MD, MPH CHIEF MEDICAL OFFICER BOSTON HEALTH CARE FOR THE HOMELESS PROGRAM Case Study: Boston in the setting of Massachusetts